Chuck and Chris Discuss Uncertainty

Season 3, Episode 29.  Chuck and Chris discuss overcoming uncertainty as based on the HBR article "How to overcome your fear of the unknown" by authors Nathan Furr and Susannah Harmon Furr.  This article from the July-August issue is based on  the book, "The Upside of Uncertainty."  We found the article and its message fascinating and related the key points in this discussion.

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Transcript

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Welcome to the upper hand podcast where Chuck and Chris talk Hand Surgery. We are two hand surgeons at Washington University in St. Louis here to talk about all things hand surgery related from technical to personal. Please subscribe, wherever you get your podcasts. And thank you in advance for leaving a review and leaving a rating wherever you get your podcasts. Oh, hey, Chris. Hey, Chuck, how are you? I am fantastic. How are you? I'm great. I'm great. I'm very excited. We had a great chat last week with farsh, you know, kind of leads us into our topic. Today, we're going to do one of our HBR leadership articles. But I did have an interesting case I wanted to share with you just get your thoughts on a concept. I love I love it. I love it. What's been your success? Or what's been your approach and success to stabilizing the unstable, etc. So extensor tendon, say at the level of zone five, so right over the MP joint sagittal band region, what's your go to for those patients? I think it's important that we I think I know where you're going with this case, but narrow it and make sure we're very clear. So you know, there are patients with multiple unstable extensor tendons. And so we're not really I don't think we're here to talk about those. I will say whatever I think about so and then in a non non rheumatoid count. Yes, yes. So an acute, traumatic, unstable extensor tendon. And I always feel the need to say, when you see one of these, it's really helpful conceptually, and they're not all that common, although I think you and I see them intermittently. And it isn't the differential for trigger finger. And when you see an impressive one, and you can see why it's in the differential for trigger. So I liked the diagnosis. I like treating it. I don't want to go down on too much of a monologue. But I guess first I would say, if it's truly acute, those patients are given a trial of a splint for six weeks with the MP joining extension, before I think about surgery and with the MP join extension, so is that purely just you're leaving the PIP free?Are you doing anything to stabilize it to the adjacent finger, and what kind of activity precautions that you give them? So for me, it's so funny the things that we all remember, but I will never forget Peter stern and fellowship. And that's many years ago to talk about George Kettlecamp's article on this, which is an old, old, old jbjs article. And it's, it's, you know, these injuries are almost always the radial sagittal band of the middle finger. And the tenants of let's say its own early. And more recently, we've come to understand that there are kind of two different splits that work in my mind. There are hand based splints, they extend the MP joint, they can truly be a P one blocker, where you simply have to have the proximal phalanx extended of that middle finger and I leave the IP joints free. Or it can be one of the splints that kind of works around the middle finger by basically keeping the middle finger up and keeping the index and ring finger slightly flexed. But I let them do what they want to do, as long as that MP join stays extended. That so for those of you that were not watching on YouTube, Chuck was demonstrating a yoke type splint in the second one. Ya know, I think a lot of it depends on for me, the patient's preferences as well as the therapists comfort level with, you know, what the patient's actually going to wear and use? And how long do you have them wear that for an acute situation. So it's a full six weeks trial for me which, you know, it's not it's not the hardest one to wear in the world. But it's definitely not the easiest, it's really inconvenient. I was exclusively using the yoke splints, I think the P1 blocking splint might be a little easier to wear. But as we've discussed many, many times, I trust our therapists implicitly and I give them the option of talking to the patient and try to understand what might work best for each patient. And Macey actually made me one when we were at the beginning of the academic year, and we were are probably going to do it again, pretty soon, is we did a session where she kind of walked us through all the splints and how they make them and everything and the common ones. And she put a yoke on me and it was not comfortable to tell you that. Yeah, well and given my age, Chris, you know that I've experienced a lot of the conditions that I talked about. But so I learned something about myself, which is that when I like get out of the shower or wash my hands, I flick my fingers and I think I had a partial sagittal band injury and I wore a splint I didn't that it was pain rather than true instability. So I think it was a partial injury. The sagittal band , I did wear a splint. For a couple of weeks that pain went away and I stopped complaining loudly to everyone, and it was a hard splint to wear. So wait, you injured yourself? Washing your hands flicking the water off my hands after I had washed them. Oh, I'm just gonna leave that one alone. So say say the patient comes to you a little bit delayed? And it isn't an acute injury anymore. And but they still have the tendons subluxation. How are you thinking about that patient say you do put them through the trial of splinting. But it gets to the point where surgically you feel like something should be done? Are the patients insisting on something should be done? How do you approach that? Well, I think it's a completely reasonable thing to do. It's still requires that period of immobilization, which is part of the the difficulty of the conversation with a quote, trial of non operative care, because if you mobilize them for six weeks, and they fail, and then you do the surgery, you mobilize them again, it's really painful. So that's a long, it's a long process, right? And so it's I don't want to, I'm certainly not advocating being super aggressive and going immediately to surgery because it's not necessary. And non awkward care works, especially in the otherwise healthy patient with an isolated acute care. But the patient with a chronic tear, I think surgery is very reasonable. And it's really about, it was about a couple of things. There's one trying to rebalance, get a good repair of the sagittal band when possible, and take away any forces that are fighting against you, which often are the juncture. So how do you, you know, so are you releasing the ulnar sided junctura? And then what if you just have a not great looking radial sagittal band? What do you do? Are you are you placating that side? Are you doing anything to tighten that up? Or are you going to more of a reconstruction stabilization? Yeah, so I think if it's a reasonable radial sagittal band, you can obtain a very satisfactory repair. And perhaps with that great repair, you could move the patient early, I haven't done that, because the quality of the tissue is just never overwhelmingly good. But if you don't have that good tissue, it gets trickier. And often, if the tissues lousy, the owner sagittal band may be contracted. So you may have to release that to get the tenon back up. But that's when the the adjacent soft tissues can be your best friend. And so if there are juncture that are really honestly on either side, then you can figure out a way to loop those juncture and help to stabilize the tendon. And so the best case scenario in my mind is if you have an owner side of juncture that you can release as far away from the effective finger as possible. And then you take that juncture, wrap it over the top of the tendon to help stabilize the tendon. And then in those situations, where it's a reconstruction of whatever type, it's a little more important in my mind to truly mobilize them in extension for that full six weeks. How do you how do you think about it? How did you do it? You know, there are a couple of cases in which I've actually just placated and imbricated that tissue over using an anchor, and inserting an anchor using that suture to placate and stabilize after only after releasing the ulnar side, and a handful of cases that's been successful. For me, the thing I'm always thinking about is like you're saying rearranging local tissue, the junk Tura. And then the thing that I saw in training in residency was Michelle Carlson had a technique where she actually drilled a tunnel into the metacarpal head and then looped around a tenant autographs to help stabilize the help stabilize, etc. I have not had to do that in practice thus far. But that's always a technique I have in the back of my mind and in case I need something to you know, kind of a last last resort kind of thing. Yeah, let me be super clear. I have never used an implant or a drill hole I respect Michelle greatly. I have always done a complete least soft tissue repair and never had any regrets. So I'm not sure that's necessary. I'm certainly not throwing stones but for me, it's not been necessary to provide an implant or tunnel or anything like that. Well, you know, we'll, we'll see how things keep coming along. But you know, I think that they my patients with this have been happy so far. I always just find it to be an interesting concept because it's one of the things where a couple of articles or you know, review article 10 of things are mentioned, but we never truly get to talk about it too much. So yeah, it's a great topic. I think it's an interesting topic is uncommon and, and but an injury that can really make you look good because I think you can help the patient obtain great results. Absolutely. So I did want to throw in we've got a great review on on iTunes. So for those of you that are listening, if you haven't left us a five star review on iTunes, please do this is from A Gaston- it says thank you Dr. Goldfarb and Dr. Dy. I love your podcasts. I'm the new CHT in Chicago. And I'm always trying to learn more about various treatment options for hand conditions, surgical techniques and how to best serve my patients. You both share so much insight in a way that keeps me entertained and informed. This podcast is a fabulous resource. I appreciate your taking your time spent recording this information you two rock. So thank you for that wonderful review A. Gaston. Thank you very much grateful and, you know, gives us fuel as we've said a million times. Absolutely. So we had a great episode last week with Farsh Gulak incredibly accomplished scientists all around fantastic person. We ended and we did not sorry to interrupt, we did not get into his science. If if arthritis at all interests you, you should look up what farsh is doing. It is absolutely fundamentally stunning. And, you know, you never know who's going to ultimately get the job done, so to speak. But I if I had to put some money down, I might bet on Farshad, this clinical trial he briefly mentioned to us and we didn't have time to dive in into it in too much detail. Sounds amazing. Yeah, and a lot of money's on that guy, I guarantee he's gonna He's gonna make a huge dent in it. You know that time he's hanging it up. And then one of his many trainees and mentees will, you know, take the ball and run with it. So definitely look into his science, if you haven't, he's incredibly accomplished. So we talked a little bit with him about uncertainty, which leads us into this week's discussion about a Harvard Business Review article about uncertainty. And this, you know, those of us that still get the print journals, Chuck, I know you had your beef with HBR recently, but I ran into this when I was reading my magazine, and it's called How to overcome your fear of the unknown. The authors are Nathan Furr and Susannah Harmon Furr for and it's from the July August edition of HBR of this year. And, you know, I think that, you know, I'll just read the first two paragraphs, because I think it's a good way to start the discussion. And then maybe Chuck, you and I can talk a little bit about some of the principles that they discuss here. Sounds okay. I would love to I guess I would, maybe if it's okay. I learned a little bit. I always like to look up the authors. They are both extraordinarily well trained. And Nathan works at INSEAD, which is labeled as the business school for the world. It's one of the world's leading and largest graduate business schools, locations in France, Singapore, Abu Dhabi, and San Francisco. And, you know, really interesting, he's a, I'm just focusing on Nathan for a second. He's a professor of innovation. And yeah, really, really intrigued. I love this business. Well, as you and I have discussed and, and really take pleasure in talking about articles like this one. Absolutely. And I know a lot of our listeners appreciate when we take a little bit of time away from the hand surgery hand therapy world to, to do some stuff that's a little more general. So this talks about how humans are wired to fear the unknown. That's why uncertainty can feel nerve wracking, exhausting, and even debilitating, however, that gut reaction leads people to miss a crucial fact, uncertainty and possibility are two sides of the same coin. Consider the achievements, you're most proud of the moments that transformed your life, the relationships that make your life worth living, we'll bet that they all happen after a period of uncertainty. One that probably felt stressful, but that you nevertheless push through to accomplish something great. So that's the intro. Chuck, can you think of any periods of uncertainty that come to mind for you that, you know, ended up being, you know, substantial to you? I can certainly think of some in the past and, you know, as I kind of contemplate, I'm at that middle age moment of crisis. For some, I don't feel like I'm in crisis, but it's super interesting time of life. And I know some of the listeners may appreciate this, or be dealing with something like this, you kind of get to this point where your kids are out of the house or seem to be out of the house and ice cream, you know, just up front of ice cream towards success. And then you know, my my dynamic is changing because friends are talking about or potentially moving away. Do I want to consider a job move, and you know, things like that are just top of mind. And in this situation, and in previous ones, it's always the same kind of thought. I understand where I am, understand what I can accomplish here. And it just feels easy, and it feels safe. But acknowledging that just as farsh did in that last episode, when he discussed the uncertainty he felt in moving to St. Louis from a really safe established place at Duke is really important. I totally get it do stay safe and maybe not be jolted enough to do as much as you could or do you think about a really terrifying move. Yeah, no, I think that at least acknowledging the fact that you feel safe, and that this feels easy, is an important thing. And, you know, I think there are many, many listeners who have had to deal with this on a personal level, whether it's, you know, a lot of times it is professional in terms of whether you move positions or move your life somewhere else. But I think that the thought process, at least of considering what you have and what potentially you might want, and what can happen, that process in and of itself is good to go through. So tell us give us an example from your life. Moving to St. Louis, you know, I think that that was, I think I've told this on the pod before, but you know, when I was so I matched for the fellowship here in St. Louis, when I was a resident in New York City, and I matched in was like May of whatever year, and I matched. And then I think it was August, and our former partner and my former co resident Dan Osei called me in August. So literally, was it three months after I matched? And said, Hey, would you be interested in coming and interviewing for a job? And I'm, like, really, like, just matched? Like, you know, that's, I know, Chuck, you're probably wringing your hands saying, What the heck are we doing interviewing somebody who hasn't even spent any time here? And, you know, so I, of course, said yes. Because that would be super awkward. If I turned down a job interview before coming out of fellowship, I was, I was flattered, I was flattered. Because you know, at that point, it still is the department, it was World beating in terms of, you know, recognition for the stuff that I valued. You know, you know, academic reputation and research potential and teaching and you know, all that. So I was talking to my wife, we were in the kitchen in our apartment in New York, and I said, Hey, I really have to go take this interview. She said, Yeah, of course, you have to do the interview. She said, There's no way in hell, we're moving to St. Louis for more than one year, literal words out of her mouth. And I said, Okay, fine. So then I remember talking to Dr. Gelberman. Secretary at the time, because he was the chair and Cheryl, I talked to Cheryl I said, I'd be happy to interview I will tell you just reality, you know, my wife and I are coming as a package deal. And she's a physician. And she is, you know, looking at jobs, too. Is there a possibility. And so, Cheryl and Dr. Gelberman, I think work their magic and set up a fantastic interview day for both of us, we actually came for a recruitment weekend. And when Cheryl sent out the itinerary, the itinerary was very nice. It was nicely put together as professional, you know, all the stuff that you would expect out of Cheryl and Dr. Gelberman. And my wife looked at the itinerary. And she said, I might fall for this. And the rest is history. But you know, that's, you know, we went on a couple of visits. And it was a big leap, because neither of us have family in St. Louis. we'd both be starting in our first jobs in our career, and certainly your first jobs are not your last jobs. But, you know, like, it was everything that I academically was everything I thought it was going to be. But we just weren't sure about raising a family and St. Louis. You know, Tiffany's from Houston, I grew up in Florida, we loved living in New York. I think geographically, we weren't sure. Family wise, we weren't sure. Culturally, we weren't sure. Because, you know, this is it was important for us to think about what it would be like to raise, you know, Asian American children in the Midwest. And, you know, it's obviously a lot easier on the coasts. So that was an important consideration for us. So in many ways, there's a lot of uncertainty for us. But we decided that we would give it five years. And at the five year mark, we've loved it. So and then we're going to check in again, if we actually talked about it last night, when we were pre ice cream we were talking about, you know, how is it so far? And I think there are many reasons why the uncertainty thing has paid off. But I mean, I think it is, you know, struggling and you know, dealing with it initially and then kind of pushing through. Yeah, essentially, it I don't want to say anything inappropriate. But I will say that when Dr. Gelberman who had and I've said this before on the podcast, has many talents, but identification of future impactful orthopedic surgeons and scientists is certainly one of his greatest talents. When he said in August, before you arrived, the following August, we're going to recruit Dr. Dy to join us, all of us have the same response, why he's good on paper, but we have a free job interview. We give it three months here next year, and we'll figure out whether we really like him. He's like, No, we need to do it now. And we need to lock him up. And you know, who argued with Dr. Gelberman? I will say, you know, looking back on the process, I was very strategic of him, because he knew my value. I didn't know my value. He could lock me up. And I would not be able to look for jobs because nobody else would be looking at somebody at that point. So I took a couple of phone calls at other places. But again, it was like way too early for them to know their situation. And he had the luxury of being the chair in the department where he could grow and put just recruit people, and not necessarily need the volume to immediately make them busy. So I think he strategically was a master. And I look at the situation, I know that the dynamic was definitely in his favor. And I'm just fortunate it worked out because he was right. It was It is It was It is a fantastic position. And I'm totally thrilled that it worked out. But yeah, so it was a little scary. I can imagine how scary it was on your eyes. And I remember the fellowship being colored by the fact that it was a year long job interview, and I kept waiting to get called into the office saying, so we've reconsider. You know, Gelberman had done a number of things as chair, I think, you know, and I don't want to give him too much credit. But I think a couple of these things are legitimately his two best of my understanding. One is the changing face of what academic orthopedics looks like, the compensation plan and the expectations and what he did way back is now standard for every orthopedic, you know, program, I think in the country. And then this early hiring, also super interesting and easier to do with it huge groups like we have harder to do for smaller groups. But wow, I think that was a an innovative approach that Dr. Gelberman took that certainly has paid dividends for us. Absolutely. And so one of the the first principle in this article is actually about reframing your situation. And multiple there's talking about here that most people are loss averse. And multiple studies demonstrate the way you frame things affects how you make decisions. And I'll tell I'll lead with a personal example. I remember coming back from the job interview, and speaking to the then Chief of the hand service Ed Athanasian, at HSS. And saying, you know, what do you think I should do? And he reframed it in a way that I thought was incredible. He was like, Look, even if it doesn't work out, just think of it as an extension of your training. You know, you're gonna go there, you're going to start as faculty, you're going to learn something, and if it doesn't work out, you can move on. And I think that, you know, as a trainee, you're always thinking, you know, again, to put it back to a basketball analogy, it's like, you want to be the the person that plays for one team their entire career, like, you know, you want to be the Kobe you don't like do you look at somebody who moves teams and moves jobs. And if there's something wrong with that, there's clearly nothing wrong with that. And you know, the statistics, at least orthopedic surgeons, they're out there, most people are, you know, at least 50% of people are moving jobs after, you know, they move on after their first job. So I think reframing that is important, don't go into, you know, at least for those that are surgeons coming out of practice, don't look, don't come out looking at your first job, like it's your last job, for sure. Right. And at this point, the author's continue along this point about stop being risk averse, or it's not stopping risk averse, or loss of versus just reframing, as you said, and they go on to talk about the infinite game theory. And I believe you have read and I certainly have read and it was impactful. Simon Sinek's book, on the infinite game, and the message is clear, right? Stop thinking about what what good can happen, what bad can happen. Think about the bigger picture in goals. And rather than a list of pros and cons, just think about your targets. You know, he says, you know, stop seeing the rules, the boundaries, the purpose of the game, you're playing the job, you're after the project you've been assigned as fixed. If you do see it as fixed, then you're stuck. It's a win, or it's a loss. But if you think about uncertainty as being part of the big picture, then it works. It just works better. But it's not always easy to do that. Yeah, I mean, especially, you know, when you're thinking about very tangible things, do I get that I get that fellowship interview? Did I get the fellowship? Did I get that job interview? Did I get the job? Did I get the grant to the paper get published. And we talked last week with farsh about, you know, how losing and not succeeding is actually part of the process. It's not, failure is not bad. Failure is just part of the process. And you know, he hit it spot on about accepting failure as part of, you know, what we have to deal with. And it's very different than patient care. You know, we're wired to think patient care, you always win, you have to win. Like you're supposed to help somebody, you walk into a surgery, you have a very tangible goal, somebody walks into your office, you have a tangible goal, and you're supposed to help them. And I think that part of the reason why I like some of the complex stuff that that I do, and I know that you like some of the complex stuff you do is that there is a little bit of that uncertainty that gives that kind of gets to keeps you engaged and makes you want to keep pushing towards a goal. But you have to accept that you know, not every pan Plexus patient is going to get better and not every patient who you're reconstructing congenital deformity is going to Get the exact function that you want. But I think it adds to the enjoyment at the end of the day because you are still working towards a goal. But you accept the uncertainty. Yeah, I think that's well said is super interesting. Because, you know, for the patient care piece, we always are striving for the win black and white. And if it can be black and white, and we get the win, great. If we don't get the win, the surgeon may still benefit in the sense that we may learn something that helps us with the other patients. But none of us are willing, well, I would hope not are willing to sacrifice the care of any single patient in that goal. And I hesitate on new procedures, for example, for that very reason. But in life, this, this framing is really helpful. Absolutely, absolutely. 100% agree with that. I got at the risk of I guess mispronouncing the Patagonia story is super interesting. And they reference Shannara, I think I pronounced his name, I don't know. But the founder of Patagonia, is deemed in this article as an infinite player, because he was sort of a misfit as a child. And he really has done things differently. To build Patagonia to the brand it is today. He's taken really big risks and challenges. And what I love about his reference in this article, it's about having a value based approach to the decisions that you make. Don't make a decision in isolation, as you know, to who you are or what you and your family want to accomplish. It all has to be wrapped up. And if you always think about and we talked about this a lot in department leadership, let our decisions be based on our values, and trust that it'll work out. Yeah. And I think that that relates perfectly to a concept that you know, the other author, we talked about Simon Sinek, in his book, start with why understanding your why is all about understanding your values. And I think without taking the time to understand your values, you're going to be making no decision, you're just going to be going from decision to decision as opposed to thinking strategically. Since you brought up the founder of Patagonia, I wanted to see your thoughts about one of these quotes, since you are, you know, a big leader in our department. He talks about how managers of a business that wants to be around for the next 100 years had better love change. When there is no crisis, the Wise Leader will invent one. So what do you think about that? It you know, it's super interesting. And that's my expression, I guess, of the day of the podcast, or whatever. So I probably say too much. I don't believe in that. And maybe that shows my naivety and it maybe it's because we're not a publicly traded major company. But you know, leadership flourishes in times of uncertainty and in times of challenge. And if they're, if everything's just smooth, and everything's smooth sailing, then you can start to question whether you need this leader or whether this leader is doing everything he or she needs to be doing for your organization, your HR department, whatever, I can promise you that there is enough stuff going on that neither Regis nor I have to create anything. We have plenty of opportunity. But it is interesting. I mean, it is. Let me give you a concrete example. The Dean asked us to bring the neuro rehabilitation division, which is made up of Physical Medicine, rehabilitation doctors, and neurologist into our department. And so nine months ago, they officially became a member of our department now that builds upon the classic musculoskeletal physical medicine rehabilitation doctors that we've had in our department forever. And so it's really, but it's a very different type of medicine. And try to look at this as a as an opportunity as a challenge for sure a cultural challenge. A challenge to me personally, to relate to people that are not orthopedic surgeons, or are schooled in the way that I've been schooled. And it has been just that it's been a challenge. But I've learned along the way. And so I think it's just it is a reframing of the question reframing of the whole process and understanding that this is not going to be a simple win, or a simple fail. This is going to be a process. So I want to ask you a personal question. And this brings us to the second principle which is priming yourself for new risks. So they talked about how some of the most innovative people in the world and some of the best leaders take risks in many domains, but they also have Some domains in which they do not take risks. For example, Steve Jobs always wearing the black turtleneck. So they talk about reducing uncertainty in one or some parts of your life it Prime's, you to tolerate it more in other parts. So is there anything in which you feel like your uncertainty is low, and you know exactly what you're getting. So that you can be have the bandwidth or the energy to be to tolerate uncertainty in other parts of your life? So it's a super complex question, I will start by saying I don't consider myself the most innovative of people. I think we all should, or eventually, we'll know our strengths. I don't know that everyone is honest with themselves about what they do well, what they could do better, and what may not just be a strength. And while I do think I can think creatively in certain realms, and I'm doing that with implant design now, currently, I don't think it comes easily to me like it comes more easily to others. But there is no doubt and I think that this is going to could be offensive, it's not meant to be, I think, for us, given the amount of our time that we spent in patient care, the more we can create a system where patient care is standardized. And of course, I you know, I do the exercise, and I get up at the same time and all those kinds of things. And I have great support at home, all those kinds of things make life more standard, and really simplify one aspect of my life. But the more we can make put the patient care in a controllable box, which is not always possible, then the more we have time and energy for the other stuff, which may require more creativity and more focus and the like. And so, you know, patient care is always going to be the most important thing to me. But a lot of the time is controllable and doable at a high level in a manageable way. Something is that fair? Yeah, that's fair. I mean, that's, that's, you're certainly entitled to your opinion. I'm gonna disagree with you, just because I think that the patient care part is the uncertainty in a lot of ways. You know, I, a lot of time, I don't micromanage my schedule enough to know whether I'm seeing 45 patients on one day, or 57. And I need to be better about that. But I also have embraced that my clinical hours are going to be uncertain in many ways. And my clinical cares is not going to neatly follow it. And yes, I could be much better about trying to standardize that. But the way that I try to minimize my uncertainties is just the very practical thing. I tried to one of our partners loves to run outside and loves to exercise outside every morning and rain, sleet, shine, whatever David's out there running, I do not want that I want to know exactly what time I can work out, I'm going to work out in the exact same conditions every morning by workout in our gym in our basement. And that's it. And I as you know, I like food. And I think about food a lot. And one of the things that gives structure to my week is on the weekend, Saturday, Sunday, going into the week, I write a menu for the week, and I shot for the week, and map out exactly based on our schedule, what dinner is going to be for the entire week. And that's my minimizing my uncertainty in that realm. And then also trying to, you know, when I can protect my time for the academic stuff that I need to do. And I think adding that structure, and minimizing the uncertainty and scheduling academic time helps me deal with uncertainty in every other part of the week. I think that's all really well said and I don't disagree with any of it a bit. I think I said it differently. But let me go back. First of all, the structure that we can apply to our lives make sense. And that can be the grocery list, or that can be the to do list. It's amazing. When I don't have a physical To Do List, when I start to feel stressed, I have a lot of different things going on writing stuff down, physically changes everything. And that's personality driven. So I really do like that. And let me go back to the patient care when I have a manageable patient care week. And again, my goal is not to minimize or decrease the number of patients I care for, but it's to best management to manage it. So it doesn't leak into other parts of my life. Right when I'm successful there. Everything else falls into place when the patient care part overwhelms and it has the last few weeks doing cases on the wrong days and all that kind of stuff. It's just harder and so trying to you know, keep that in its lane. Not possible always. But when possible. It is something that I feel really opens up the rest of my life whether it be at work or at home to more success. Absolutely agree with that. I mean, crushing a crushing a clinic in a way where you get everything done, everything's happy, everybody's happy. You've you've gotten your notes done and you're walking out at the time you intend to walk out that feels so good and then not having to do cases on off days although that's the reality of you know, call etc. I agree with the entire only on the on the to do list thing that had structured when I'm starting to think I'm getting a little bit overwhelmed. And that brings us to our next stage about doing something. Well, and I like this, it goes again back to what Farsh said, when he had a, I don't know if he didn't really say it this way. But clearly he had a long horizon of view of what the goals were that he wanted to accomplish. And so number three is do something. Taking action is one of the most important parts of facing uncertainty, since you learn with each step that you take. And so taking that first step is absolutely critical. And I think we all know that once we take a step may end up being in the wrong direction. But when you take the step, I think you can exhale a bit. Yeah, absolutely. I mean, I think that you, you just need to get the ball rolling, get some momentum and get something moving towards that big goal. Once you get overwhelmed by the big goal, thinking that you have to hit a homerun every time you're a bat. That's the problem. You know, so whether that's clinical care, or research, I mean, you know, in the research from when people are reviewing grants, they like to use the word incremental as a bad thing. And, you know, farsh mentioned that, you know, he specifically said incremental, but in a good way. Because you need to take those small incremental steps, the baby steps before you can learn to run before you can actually put enough together where you can make a difference. But you've got to start somewhere. Yeah, and then the same point, they had another interesting look, take on values. And they emphasized the role of values rather than goals. And I think it's both honestly, you gotta have goals, because they can guide you. But if you obsess about the goals and the the meeting or not meeting other goals, then you don't have you have a finite game, right? And then you can lose. And so yes, have some goals, but really be about the value based process, rather than the meeting or not meeting specific goals, right. And then the values all tie back to that why, like, what's, what's the reason you're doing all of this? And, you know, again, understanding your values will that'll be your compass. Although I think I agree with you, I think you need the goals as you know, as guideposts. Yeah. And then the fourth point, which I think is, it's interesting, how many of these very business see articles have points like this, and it's sustained yourself. It's about taking care of yourself. And as we continue to talk about finding ways that you can address failure, you can position yourself for success. And it's an individual understanding of what makes you tick, and how you can most successfully move forward. Yeah, and I think that this definitely speaks to the concept of burnout for sure about because if you don't have a good way to be attentive to your, what he calls your emotional hygiene, so attending to your emotions, as much as you would have physical wounds, so that they don't turn into paralyzing self doubt, or unproductive rumination and reality checks in which you recognize that failure is part of the process. You know, it's a practice of medicine for a reason. You know, again, like you're saying nobody wants as a patient, nobody wants to be on the learning side of things in terms of learning curve. So we strive for excellence and perfection in every way. But recognizing that we as physicians, and therapists and health care providers, we need to be able to record and have insights and take care of ourselves emotionally, in terms of trying to figure out how we can, you know, bounce back, and, you know, help the next patient. Yeah, yeah, I think that's well said, if it's okay with you, I'm gonna read the closing paragraph or part of it, which I think is really good. It says resilience, being able to take a blow and stay standing is important. But we argue for something more learning to transform uncertainty into opportunity, the only way for any of us to tap into new possibilities through the gateway of the unknown. And it doesn't have to be a painful process, if you believe in your ability to navigate it. Our hope is that you use our advice to transform your relationship with change, and inspire others to do the same. It is about framework and I really liked this article, thank you for sharing it. Yeah, happy to do it. I think it's a good one. And I think that it's a, it's one that I will probably put in the archive to go through with the trainings on my rotation because I like it a lot. And I think that there's so many ways in which all of us can relate to it. So hopefully, you that are listening. If you have you know, check out the article. If you liked the episode, let us know. And you know, share your pearls on how you've dealt with uncertainty or if you're wanting Chuck's advice on something because he's got far more experience. So feel free to send us an email Handpodcast@gmail.com Or find us on social or leave it in a review and let us know we'd love to hear from you. Absolutely. And Chris, I am certain that you're not going to be in the office too much longer, but I hope you have a good day while these these manuscript provisions from jbjs are saying otherwise. I'm gonna get back to dealing with my personal failures right now. Awesome. Have a great day. You too. Take care. Bye. Hey, Chris. That was fun. Let's do it again real soon. Sounds good. Well, be sure to check us out on Twitter at Han podcast. Hey, Chuck, what's your Twitter handle? Mine is at congenital hand. What about you? Mine is at ChrisDyMD spelled d-y. And if you'd like to email us, you can reach us at hand podcast@gmail.com. And remember, please subscribe wherever you get your podcast and be sure to leave a review that helps us get the word out. Special thanks to Peter Martin for the amazing music. And remember, keep the upper hand come back next time